Myocardial ischemia secondary to dual coronary artery fistulas draining into main pulmonary artery

Bilateral coronary artery to pulmonary artery fistulas is an uncommon congenital anomaly. These fistulas have a clinical and embryological significance. We report a rare case of combination of right coronary and left circumflex coronary fistula draining into main pulmonary artery, who presented in the emergency room with acute pain chest. The fistula had significant 1.7:1 left to right shunt and also myocardial ischemia as demonstrated by exercise Thallium201 SPECT myocardial imaging. He was managed conservatively during the last 5 years without any percutaneous or surgical intervention.